REV.CHIM.(Bucharest)♦ 68♦ No. 8 ♦ 2017 http://www.revistadechimie.ro 1923

Negative Pressure Therapy in AbdominalCompartment Syndrome

BOGDAN MIHNEA CIUNTU¹*, CIPRIAN VASILUTA¹, NICOLETA ANTON², ROXANA CIUNTU², MIHAELA DAMIAN³,ADI CIUMANGHEL³, MIHAELA BLAJ³*, DOINA AZOICAI4, STEFAN OCTAVIAN GEORGESCU¹¹ Grigore T.Popa University of Medicine and Pharmacy, Faculty of Medicine, Department of Surgery, 16 Universitatii Str., 700115,Iasi, Romania2 Grigore T.Popa University of Medicine and Pharmacy, Faculty of Medicine, Department of Ophthalmology, 16 Universitatii Str.,Iasi, Romania3 Grigore T.Popa University of Medicine and Pharmacy, Faculty of Medicine, Department of Anesthesiology and Critical CareMedicine, 16 Universitatii Str., 700116, Iasi, Romania4 Grigore T.Popa University of Medicine and Pharmacy, Faculty of Medicine, Department of Preventive Medicine andInderdisciplinarity, 16 Universitatii Str., 700115, Iasi, Romania

The abdominal vacuum-assisted closure (VAC) system has been introduced, providing a new possibility totreat an open abdomen. Abdominal compartment syndrome has a great relevance in surgical practice andpatient care in critical condition due to the effects of increased pressure in the enclosed space of theabdomen can lead to multiple organ failure. A prospective study was conducted on a sample of 15 patientswith severe acute pancreatitis (SAP) was retrospectively analyzed, following the incidence of intra-abdominalhypertension (IAH) and abdominal compartment syndrome (ACS),the effectiveness of the therapeuticmethods applied in reducing the intra-abdominal pressure (PIA), the evolution of severity scores, lenght ofstay in intensive care unit between January 2014 - March 2017, following negative pressure therapy. Therewere used vacuum assisted closure devices (VAC ™ -Hartman) in order to apply negative pressure to theopen abdomen, while complying with specified settings in accordance with patients’ outcome. Surgery forabdominal decompression in PAS with SCA is an emergency and was imposed on 14 of the 15 patients . Inthe studied group, the first decompression procedure was performed on days 2 to 5 from intake, as PIAincreased in evolution despite medical methods. Only 1 patient hospitalized with SAP PIA decreased bymedical methods and after haemofiltration. Acute severe pancreatitis remains a serious pathology in spiteof a maximum medical and surgical therapy.Continuous venous haemofiltration has contributed to loweringintraabdominal pressure. Surgery with decompression vacuum systems with negative pressure lead to asignificant decrease in PIA.

Keywords: Negative pressure therapy, comportament syndrome, acute pancreatitis

Abdominal compartment syndrome (ACS) in patientswith severe acute pancreatitis (SAP) is a marker of severedisease. It occurs as combination of inflammation ofretroperitoneum, visceral edema, ascites, acuteperipancreatic fluid collections, paralytic ileus, andaggressive fluid resuscitation.

IAH has been defined as an intra-abdominal pressure(IAP) of 12mm Hg or higher [1]; this is the threshold atwhich organ dysfunction may set in, although it is oftenundetectable unless specifically sought for.

Intra-abdominal hypertension (IAH) and abdominalcompartment syndrome (ACS) have been found to besignificant contributors to organ dysfunction in a variety ofcritically ill patients, and several strategies have beendeveloped to prevent and treat ACS [2].

In case of ACS, the IAP is 20 mmHg or higher withclinically evident new organ dysfunction; acute kidneyinjury, cardiovascular instability and respiratory insufficientare the most often encountered organ dysfunctions in ACS.IAH and ACS are typically an early phenomenon in SAP andin most reports IAH develops in the first 3-5 days afterhospital admission [3].

Pancreatitis is a dynamic disease with a rapid andunpredictable development where complications changethe course of the disease. Severe acute pancreatitis stillpresents a high mortality rate due to its numerous localand / or general complications, regardless of the etiology

of the disease, despite progress in diagnosis, therapy andsurgical treatment. Clinical examination is notoriouslyunreliable in diagnosing IAH and ACS, but IAP measurementshould be now in the armamentarium of all contemporaryICUs. The bladder is used as a window to the abdomen,and several methods for reproducible IAP measurementare now available. Several reviews describing thetechniques for IAP measurement have been published [4].

The incidence of intra-abdominal hypertension (HIA) insevere acute pancreatitis (PAS) is reported between 60-80% being prematurely installed due to inflammation, fluidaccumulation, ileus but also aggressive volumetricresuscitation.

HIA is reported from admission at pacientis with PASbut worsens within the first 3-5 days of intake, frequentlyleading to abdominal compartment syndrome (SCA).

Mortality in PAS associated with SCA is 49% comparedto PAS cases without SCA where it was 11% [5].

The HIA reduction protocol targets:Nasogastricdecompression and prokinetic use, adequate fluidmanagement, hemodynamic guidance with invasivemonitoring, PICCO, contour pulse analysis, early initiationof haemofiltration using the cytokine absorption filters,percutaneous drainage of peritoneal collections, surgicalabdominal decompression surgery with temporary openabdomen with continuous negative pressure system(According to the recommendations of the InternationalSociety of Abdominal Complication Syndrome).

* email: bogdanmciuntu@yahoo.com; miblaj@yahoo.com

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When non-operative measures fail to decrease IAP andto improve respiratory, renal and cardiovascular function,one should consider surgical decompression (de-compressive laparotomy) (6).

Experimental partMaterial and method

A prospective study was conducted on a sample of 15patients with severe acute pancreatitis (SAP) wasretrospectively analyzed, following the incidence of intra-abdominal hypertension (IAH) and abdominalcompartment syndrome (ACS),the effectiveness of thetherapeutic methods applied in reducing the intra-abdominal pressure (PIA), the evolution of severity scoresand lenght of stay in intensive care unit between January2014 - March 2017, following negative pressure therapy.

There were used vacuum assisted closure devices (VAC™ -Hartman) in order to apply negative pressure to the openabdomen, while complying with specified settings(negative pressure, time of use of a kit) in accordancewith patients’ outcome.

Determination of PIA with a device by attachment to a50 mL closed circuit urinal probe and a pressure transducerincluded. The PIA value is displayed on the monitor inmmHg.

NPWT dressing has been designed according to thewounds, which are then sealed with a semi-permeablefilm from the kit.

Pressure level was set individually for each patient basedon their needs, using continuous suction initially, andintermittent suction subsequently.

Pressure settings were dependent on the local conditionsof the wound and pathological conditions of thepatientwere considered.

Dressing change was performed every 48-72 h bydoctor.

Results and discussionsIn relation to the admission of the patients in the hospital,

their number was variable.Demographic data revealed an average age of 59.28

years with a women to men ratio of 6: 9.Causes of severe acute pancreatitis were in 6 cases

vesicular lithiasis, in 5 cases toxic, in 3 cases after surgicalprocedures and in one case idiopathic.

APACHE II on admission was 19 (average). Average PIAvalue at admission was 22.28 mmHg. Upon admission, allpatients had PIA> 12mmHg and 53% (8 patients) had PIA>20mmHg. PIA growth trend from PIA(initialy) of22.28mmHg to day 3 PIA 24.37, p = 0.8 (fig. 1).

Protein C reactive increases from 20.55 units in day 1 to28.44 units in day 3. Positive hydrating balance was morethan 2000ml in day 1 and 2 : day 1 = 3375.90mL, day 2 =3159.54mL, day 3 = 1718.20mL (fig. 2).

Hemofiltration was performed in 10 patients (67%). Itwas initiated even though patients did not have kidneyfailure, controlling the water balance and reducing theinflammatory response. After 48 hemofiltrations continuedvenous venous PIA decreased in all patients.

14 out of 15 patients (93%) for decompression surgery,followed by a decrease in PIA in the first 24 h after surgicalintervention (table 1).

PIA decreased to only 10 out of 14 patients operatedwith temporary open abdomen and continued negativepressure.

Surgery for abdominal decompression in PAS with SCAis an emergency and was imposed on 14 of the 15 patients.In the studied group, the first decompression procedurewas performed on days 2 to 5 from intake, as PIA increasedin evolution despite medical methods. Only 1 patienthospitalized with PAS PIA decreased by medical methodsand after haemofiltration. (fig. 3,4).

Fig. 1

Fig. 2

Fig.4

Fig. 3

Fig. 5

Table 1

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The number of abdominal interventions was between1 and 9 interventions (needing to change the vacuum to48-72 h) (fig.5-8).

Complications associated with these devices wererelated to sealing difficulties in 2cases.

PAS complications possibly aggravated by negativeaspiration were hemoperitoneum in 6 cases and digestivefistulas in 4 cases.

In 3 cases that had an evolution duration of> 4 weeks,the abdomen was closed at 10 days, 14 days andrespectively at 21 days.

Survival at 28 days was 6 out of 14 patients whichunderwent surgical intervetions (57%), and at 90 days 4out of 14 patients (28.5%).

Evolution of PAS and SCA cases (table 2).

Mortality due to acute pancreatitis complicationsreaches two peaks: half of the premature deaths in thefirst week of illness due to the massive inflammatoryresponse leading to multiple organ failure, increasedabdominal pressure and compartment syndrome. In thelate stages of the disease the major causes of death areseptic complications due to pancreatic necrosis andhaemorrhage.

In the context of acute pancreatitis, the effects of IAHmay have an important impact, not only on organ functions,but also on pancreatic perfusion. Animal studies have foundthat pancreatic perfusion is decreased in IAH [7], whichmay further increase the risk of pancreatic necrosis. Alsobacterial translocation, the presumed pathway forpancreatic infection in severe acute pancreatitis (SAP), isfrequent in IAH. There is a dose dependent relationshipwith the extent of bacterial infection. The macrophages, Tcells and cytokines (Interleukin-1-beta) cooperate insynergy to destroy B cells. Insulin dependent diabetesmellitus is the result of this action [8]. The expression ofproinflammatory cytokines and other mediators, includingadhesion molecules, suggests that the inflammatoryprocess may contribute to the vascular disease in diabetesmellitus [9]. Numerous experimental studies prove thecapacity of the vegetal polyphenols to diminish the lipidperoxidation and to reduce the LDL oxidation [10].

Acute pancreatitis is a typical SIRS caused by localinflammation in the pancreas

Prolongation and exacerbation of SIRS may lead toactivation of neutrophils, the coagulation system, andvarious humoral mediator cascades, and various mediatorsproduced from these cascades may cause vascularendothelial injury, cellular injury in vital organs, anddisturbance of organ perfusion. As a result, organdysfunction may develop, resulting in SAP [11].

Excessive production of inflammatory cytokines fromimmunocompetent cells triggered by insult plays pivotalrole in the pathophysiology of SIRS. As SIRS plays animportant role in the pathophysiology of SAP and theprinciple feature of SIRS is hypercytokinemia, it is safelyassumed that a counter measure against hypercytokinemiais effective in the treatment of SAP.

Fig. 6 Fig. 7

Fig. 8

Table 2

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It is reported that continuous hemodiafiltration using apolymethylmethacrylate membrane hemofilter (PMMA-CHDF) can effectively remove cytokines from the bloodstream and that thereby it is useful for preventing or treatingmultiple organ dysfunction syndrome (MODS) [12].

Timing of surgical decompression is a topic of interestnowadays. It should not be surprising that in cases ofprolonged exposure to high IAP, organs function isirreversibly damaged, but the exact time frame withinwhich decompressive laparotomy can be successful isdifficult to determine. Depending on the underlyingpathology, chronic wounds and swelling are oftenconcomitant, and accumulated excess fluids beingaccepted as a contraventional healing factor by thecompression effect exerting locally on cells and tissues.Applying negative pressure in these situations reducesextracellular fluid accumulation resulting in a better bloodperfusion [13].

Microbiological surveillance of the wound after initiationof negative pressure therapy was shown to significantlyimprove the evolution, with an important reduction in thecontamination of the wound. From a clinical point of view,necrosis was produced in a limited number of cases,obvious remission of SIRS and hipercatabolic syndrome[14].

The resulting open abdomen should be managedappropriately. Whereas this once used to be the surgeonsnightmare, negative pressure therapy has become thestandard of care for the open abdomen, with the lowestcomplications and the highest primary fascial closure rates[15].

Also in patients with severe acute pancreatitis (SAP)this method has been used successfully [16].

Using a mesh-based technique has been found the mostsuccessful method in achieving early abdominal closureand a significant decrease in PIA [17]. Vascularcomplications arise through numerous mechanisms:enzymatic erosion with breakage of the vessel wall,formation and rupture of an aneur ysm or venousthrombosis. Depending on vessel location andpathogenesis, bleeding may occur in the gastrointestinaltract, in the peritoneal or retroperitoneal cavity.

ConclusionsAcute pancreatitis is an entity that raises numerous

diagnosis and treatment problems with unpredictableevolution, being a real challenge.

Establishing a rapid diagnosis and placing it in a riskcategory through severity is of at most importance. IAPmonitoring is a first and essential step in the diagnosis andtreatment of IAH.If medical therapy fails, decompressivelaparotomy may be an appropriate option to reduce IAPand restore organ function.

Acute severe pancreatitis remains a serious pathologyin spite of a maximum medical and surgical therapy.

Continuous venous haemofiltration has contributed tolowering intra abdominal pressure.

Surgery with decompression vacuum systems withnegative pressure continues to lead to a significantdecrease in PIA.

Treatment of laparostomy with VAC for abdominalcompartment syndrome results in a high rate of successfulabdominal closure and we recommend vacuum therapyin such cases, the technique proving its usefulness in themanagement of PIA.

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Manuscript received: 14.01.2017